Clinical commissioning groups: how to ensure their first birthday isn’t their last

Cake

It is more than a year since clinical commissioning groups (CCGs) formally came into existence in England, and although strategic plans are slowly beginning to emerge, CCGs continue to struggle with an infrastructure originally designed to control a national system.

The 2012 Health and Social Care Act saw CCGs as the mainspring of commissioning, capitalising on general practitioners’ twin roles: dealing with patients at the ‘front door’ of the NHS and referring and coordinating their journeys through its complex institutional pathways when necessary. The notion was that general practitioners’ (albeit anecdotal) knowledge of local services could be synthesised to inform operational and strategic commissioning throughout the NHS. Giving CCGs the freedom to change services in their local health economies was intended to encourage innovative models of care that were more user friendly and (hopefully) better value for money.

However, CCG leaders found themselves the late arrivals at a party already in full swing. NHS England had established the ground rules, subsumed specialist commissioning and primary care, and determined how CCGs should work and be managed. And adding to the harsh financial pressures, CCGs found their budgets being raided for contingency and efficiency funding as well as for augmenting specialist commissioning, maintaining pre-existing private finance projects, and supporting social care initiatives.

In terms of how to engage and enthuse newcomers, this is not what textbooks recommend, but for the current policy to work CCGs must pull their weight. How can this be achieved? CCG development seems to parallel adolescence. By the time children leave home to live independently, they need to be able to deal with the physical, financial, and emotional hurdles that they will inevitably face: they must shoulder responsibility and risk.

Similarly, CCGs were intended to assume increasing responsibility for services and develop a mature relationship with NHS England through the area teams and commissioning support units. Many have commented that this is not happening and that a form of indirect cajoling has developed instead. Despite a few signs of change (such as NHS England accepting an annual survey of its performance by NHS Clinical Commissioners), the general sense is that CCGs are under-resourced in human and financial terms and that the need to cope with what is operationally urgent is preventing them from dealing with what is strategically important. If CCGs are not allowed to develop sufficient self determination, their growing frustration and enduring dependency will drive their participant general practitioners to lose interest at best and throw adolescent tantrums at worst.

CCGs were intended to be clinically driven by autonomous professionals who function better as volunteers than as conscripts. However, such professionals (especially independent general practitioners) traditionally lack experience of corporate working, and so encouraging them to consider collective needs as well as those of their individual patients and practices is key to the success of their CCG.

This is a complex challenge that needs tackling at various levels. Overt CCG leadership requires organisational expertise as well as a thorough knowledge of local context. Many of the clinical chairpeople and accountable officers still need to learn more about strategic thinking, which takes commitment as well as protected time and funding. Whether it is even possible remains to be seen; CCGs vary greatly in their arrangements and ambitions and even the roles of clinicians and managers differ considerably.

Leadership needs to be mirrored by support among members; clinical commissioning cannot succeed without ‘grass roots’ input informing strategic thinking. Support will vary, and senior (strategic) CCG staff will have different perspectives from frontline (operational) clinicians. Such differences have never previously been bridged, and consequently individual clinical decisions have rarely influenced high level strategy. If CCGs are to exploit their potential fully, this aspect of their functioning needs a lot more development, which also takes time and money. So far, neither has been prominent, with most attention being paid to traditional senior NHS leadership, and almost none apparent to its corollary, what we might call ‘followership.’

Another obstacle to the successful development of CCGs is that the commissioning of primary care is separate to that of secondary and community services. CCGs control most of the latter two but none of the former. If a CCG decides to replace a traditional hospital service with a primary care alternative, it can decommission the first but cannot directly commission the second.

If CCGs are to hold responsibility for providing healthcare for their populations (the idea implicitly underpinning their creation), then this mismatch must be removed to give them the tools and accountability needed to provide services. If we believe in localism at all, then how they use these tools should be their decision; if they choose to provide services within their own organisation rather than subcontracting with local NHS Trusts, then that needn’t constitute a conflict of interests as long as the accountability is in place.

Outcomes such as agreed levels of morbidity, patient satisfaction, timeliness, and financial probity all offer measures of accountability irrespective of the agency involved. As it stands, CCGs are unlikely to change their paradigms of care because current mechanisms discourage change rather than rewarding it. Moreover, any existing momentum is likely to dissipate as those involved become increasingly disillusioned.

With the NHS caught between rising demand and lessening funding, the system will increasingly have to do more for less. Giving working clinicians some responsibility for achieving this, by connecting their daily activity to strategic leadership, seems logical. But CCGs will have to be supported much more emphatically, politically and operationally, if we want health service policy, local services, and the needs of the whole local population to be brought together coherently.

This is a slightly revised version of a paper prepared in collaboration with Michael Dixon, and first published in the BMJ (online 2 April 2014 as BMJ 2014;348:g2306).

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A&E departments and the M25 effect

I’ve just done a shorImaget slot on the local radio, talking about the ‘crisis in A&E’. It was based on the new report by the Health Select Committee that highlights the issues, but says very little that is new about their solution. We know that A&E is the ‘safety valve’ for the system, we know that the patients are confused about its role, and we know that fewer and fewer doctors choose to work there.

However, the solutions mentioned by the Committee are almost entirely structural and unimaginative: beefing up the Urgent Care Boards from small talking shops into larger talking shops really isn’t the answer; neither is a vague exhortation that Ambulance Trusts should become ‘care providers in their own right’.

Perhaps it would be helpful to reframe the issues, and consider them in a slightly different way. If we look at A&E from the perspectives of hospitals providers, of those working in the community, and of patients themselves, we might get a more rounded view of the problems and maybe their solutions.

Hospitals are under tremendous pressure; they have to see patients referred to them within eighteen weeks, admit acutely ill patients from Casualty in under four hours, and do it all within ever tighter financial and quality constraints. To deal with the front door issues posed by A&E, they have introduced more and more services there, so that for many patients, turning up at the emergency department offers a ‘one stop shop’ solution to their problems. The paradox is that the more that is provided at A&E, the more the service will be used.

Clearly, the corollary of reducing services at the front door is probably not a viable option in political or practical terms, but at least we should be aware of the dynamics of supply and demand in this setting, and think twice before we get seduced by more manifestations of the M25 effect.

From a community services perspective, it’s worth asking what the incentives and disincentives are to sending people to A&E: in the middle of the night, at an ill patient’s bedside, when relatives are panicking, no other care facilities are available, and the hospital light is on (to use Stephen Dorrell’s image), why shouldn’t the ‘on call’ clinician send the patient into hospital?

The presence in NHS111 of a telehealth service that seems to do no more than signpost the road to A&E doesn’t really help either; one of the reasons we have trained professionals is to cope with risk and uncertainty in a way that an algorithmic system simply cannot do, and offering a cut price alternative was predicted by everyone but the party politicians not to work.

From the poor benighted patients’ point of view, they are faced with the emotive issues of ill health, with little or no information, often on their own, fed by a media diet of Holby City on the telly, and instant gratification in all other aspects of their lives; they also know that if they call their GP they will have a battle to be seen promptly, and if they ring NHS 111, they will probably be told to go to A&E; so once again, what’s the disincentive for them?

Complex issues cannot usually be solved with simplistic sticking plasters, so whatever single concrete suggestions are made will not be enough; indeed, given our track record, playing around with the system (any system) in a ‘quick fix’ sort of way often compounds the problems, and puts different parts of the system under strain.

However, applying a deliberately opaque and undefined solution, whilst harder to quantify and assess, does allow the system (and particularly individual professionals within the system) to use such a solution constructively and effectively, and to feel more involved in that solution; ownership is a recurring theme in all the current manipulations of the public sector.

Thus, giving Acute Trusts a new process measure to meet, such as a new Trolley time target would merely stimulate a new ‘gaming’ solution (what is the real purpose of medical assessment units, for example, if not to take the strain off the A&E four hour target?).  However, contracting with the CCGs for an outcome measure of reduced admissions (and giving them control of the resources currently involved) would allow them to be inventive and innovative in their approach, involving their own professionals, and letting them see the direct benefit to patients, to hospitals, and yes, to their bank balances too.

The GPs who are involved in running CCGs aren’t bad at understanding health and illness, and the ways in which patients are involved (or not) in their care; they are also infinitely practical and pragmatic, so if given the tools to create a solution to a problem with which they empathized, then we might begin to see some progress.

Without their ‘buy in’, no single prescription can ever work, even for Bruce Keogh and Stephen Dorrell.

 

This piece is based on one first published in Pulse Managazine on 24 July 2013, entitled ‘Another sticking plaster for the A&E compound fracture’

A snack that you can eat between blogs without ruining your appetite

I’ve been very busy this week, and haven’t had the time to do a full length entry.

However, I was involved in an interview with The Consultant magazine, part of a feature that they were running on commissioning.

The link to the magazine is: http://tinyurl.com/o25jxmo, and it may be worth a look.

Hopefully, I’ll be back on track in the next few days with a full blown article here.